Comment by bezalmighty | Hacker News Reader

Comment by bezalmighty | Hacker News Reader

Try and break the problem down with systems thinking. Here's an example of this:

  ━━1=> The output effect you're trying to eliminate/reduce is pain and swelling in respiratory tract.
    ┗━━2=> Hypothesis (needs testing): This is caused by physical irritation of the tube
       ┗━━3=> Hypothesis (needs testing): That irritation is caused by A) friction and B) physical pressure
          ┣━━4a=> How can we reduce friction?
          ┃  ┗━━5a=> Would a lubricant on the tube meet engineering constraints and reduce friction?
          ┃     ┗━━6a=> Would the use of lubricant in practice create added risks or difficulties in the operating room?
          ┃         ┗━━7a=> Hypothesis: Yes, due to the application of lubricant necessitating a glove-change afterwards.
          ┃           ┗━━8a=> How can we overcome problems with lubricant application to the intubation tube?
          ┃              ┗━━9a=> Would passing the intubation tube through a no-mess, easy-to-use "self lubricating ring" mitigate added risks or difficulties in the operating room?
          ┗━━4b=> How can we reduce physical pressure?
             ┗━━5b=> Would reducing the diameter meet engineering constraints and reduce pressure?
                ┗━━6b=> If there is a minimum diameter requirement needed to deliver oxygen, would dynamically changing the diameter of the tube (e.g. inflating it) after insertion create a reduction in pressure?

So that's a very simplified example of how to solve problems with systems thinking (although in reality it would be WAY more detailed and actually test each hypothesis).

The problem is very rarely "money" in medical fields, the problem is someone actually identifying the root problem/s, i.e. the "problem behind the problem behind the problem", and applying engineering to solve that, which solves the problem one level above it, etc.

If you're interested in this, read up on things like "the five whys", a systems approach to problem solving invented at Toyota.

Meta:

Thanks for presenting this in this format, it helped me visualize how this process would work.

We use the five whys at work to great effect, to such an extent I actually look forward to COEs.

Your comment put a name to this domain. I'd like to learn more about systems thinking. Are there any books you recommend?

I can recommend material from Donella H. Meadows. The book “Thinking in Systems” is a very good one.

https://www.goodreads.com/book/show/3828902-thinking-in-syst...

I don't want to be overly critical, but what exactly do people see in this book that eludes me?

I've read it a few months ago with high expectations, pen in hand, but… I didn't really make many notes.

Sure, if you've never heard about feedback loops (and that there is positive and negative feedback), but, is the book just way too basic for me or did I miss the point?

Is Weinberg's book maybe more practical or more advanced?

I'm still thinking that systems thinking has much to offer (and skimming the International Encyclopedia of Systems and Cybernetics confirms that hunch), but where do I continue?

I also want to compliment you on the format.

I don't think inflating would work, since it's a tube. Maybe you could achieve the same thing with a sort of skeleton inside the tube that can push it to different widths.

Such a “sort of skeleton” is called aan expandable stent (https://en.wikipedia.org/wiki/Stent).

I wouldn’t know whether that would help, though. I think it’s at least equally likely the problems are caused by having to make fairly tight turns in a tunnel that changes shape all the time.

I appreciate your method of breaking down the problem. I'm still stuck on the idea of using different materials but after applying your thought process I think a gelatin coating may solve the lubrication issue and possibly allow a topical numming agent like Ambesol or anti inflammatory to be infused in the gelatin layer.

It is possible that because my procedure ran longer than expected due to complications, they either had to reinsert a different tube or the tube they used was not designed to be used for that long.

I had my gallbladder removed and unfortunately some of the gallstones got stuck in the bile ducts and they had to chase them down. This turned a 45 minute procedure into a 3 1/2 hour operation and once finished it took another 2 hours to wake up.

I don't know what kind of anesthesia you were on, but a quick google suggests some kinds of anesthesia cause difficulty swallowing. I also can easily pull up a link suggesting that dehydration is a common cause of sore throat following any major surgery.

So this may not be entirely about the physical contact of the tube.

I am not a doctor, just someone who has seen too many of them over the years for my own medical dramas.

Edit: Just to be crystal clear, I am absolutely not trying to suggest anything for you, medically speaking. The above observations are food for thought concerning the problem space under discussion. That's it. That's all it is.

The issue with coatings and lubricants is that you’d need to use a nontrivial amount for them to be effective, and that means the patient is at risk of aspirating the substance. That happens, and boom, you’ve got aspiration pneumonia. Even with some kind of encapsulated or solid gelatin coating you’d have to be very careful to make sure it doesn’t leave any kind of residue or break into pieces that could be aspirated.

Considering solid materials with ultralow friction (e.g. fullerene-like nanostructures) might be worthwhile.

https://pubmed.ncbi.nlm.nih.gov/21825776/?dopt=Abstract

https://pubmed.ncbi.nlm.nih.gov/11001049/?dopt=Abstract

https://doi.org/10.1088/0022-3727/39/18/R01

https://doi.org/10.1063/1.1366649

This is a dumb idea that would presumably cause other problems but ... what if they put the patient upside down? It's certainly make using some sort of lubricant a lot less dangerous. Now presumably it would introduce a host of other problems that would offset this but who knows.

Pretty interesting annotation. Looks like an absolute nightmare to do by hand, but it does clarify my thinking process. Thank you.

TL;DR 1. Consider Ishikawa (“fish bone”) diagrams before applying the 5 whys or as a way to help organize the 5 why process.

2. To improve a system, first determine what is constraining the performance of the system. This is 80/20 thinking and attempting to optimize globally instead of locally. Local improvement may not result in system improvement.

Longer explanation and examples follow.

1: The 5 whys are a great problem solving tool. Often there are many potential root causes which need to be investigated. Sometimes there is a single root cause that is responsible for the problem being investigated other times there are multiple factors that interact to cause the problem.

An Ishikawa or “fishbone” diagram is a useful tool to help organize many potential root causes.

In the example of pain and swelling caused by intubation we could start a little higher before diving into detailed 5 whys.

We can start with top level groups, such as: - material - method - person - patient

For each group, we determine potential root causes. This can be done through asking the experts performing the process, reviewing SOPs, observing the process, looking at process parameters, literature reviews.

Some examples, material could be the material of the tube, the type of coating being used, anesthesia, etc.

Method could be how the tube is inserted.

Person can be if the person is new to the process or experienced, is the person following procedures...

Patient could be if the patient has any allergies to materials or adverse reactions to medication or anesthetic...

The above are illustrative. You can decompose the groups in different ways. You can define the groups differently. Of course the above isn’t comprehensive or unique. Try to be MECE or mutually exclusive and collectively exhaustive when decomposing the problem space.

We often try to investigate the potential root causes by performing statistical experiments to try and determine cause and effect and which variables significantly impact the outcome.

2: I want to provide an alternative point of systems thinking. The medical procedure is a process. There is a system at work to deliver that medical procedure. There are measurements to determine how the procedure is working. Efficiency (are you using the resources planned) and effectiveness (are you achieving the outcome the procedure was designed to provide) are two high-level ways to look at measuring system performance. Many measurements can be derived from these two.

From that perspective, you want to focus improvement on the areas/steps in the process that will most improve the outcome measures. With that in mind, it may have been determined that the combination of intubation materials and procedures that are used provide for the best outcomes as determined by the procedure provider. It may be to reduce cost while keeping recovery, discomfort, risk of infection, etc. at some baseline acceptable level. If you change those variables to reduce discomfort, it’s possible you may negatively impact cost, patient recover, or something else.

Note: I’m not a health care professional, so I have no knowledge about medical procedures or the various trade-offs and optimizations that take place. I am speaking from the point of view of someone who works in quality and process improvement.

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